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I had to quit my job because of the stress I had to endure was putting me at high risk for a stroke or heart attack and I couldn’t physically keep up anymore
I’m 56 years of age
My job was 32 hours a week
But because of Obama care my insurance was costing me $600 dollars a month for just major medical!
No dental no eye care no life insurance
So by the time I paid my rent, electric, water, sewer, garbage, car insurance, house insurance etc, I had enough money to put gas in the car to get to work and buy ramen noodles and some cheap hot dogs for food!
Over 60% of my net pay went to insurance that covered nothing!
Now I am unemployed with ZERO insurance
Its pretty damn sad when all the damn medicaide and dissabilty cheats are eating steak with perfect teeth and new glasses and are in perfect health while I have to bust my damn ass just to eat ramen noodles wityh bad teeth , basbasd eyes, and life threatening health problems!!

So here I am, no job, no insurance, no hope

Patient’s story as posted on Obamacare stories

The average household income in the United States is $51,000. From that you pay for our food, shelter, children’s education, and movie tickets. Oh, yeah, and $5000 for a health insurance policy. One of the things that Obamacare did was begin to put a cost on our insatiable healthcare consumption. Turns out, that cost is VERY high.

If you are an average American, boy are you ticked off. Half of all Americans spend under $400 a year on healthcare. Pretty much a round of antibiotics for a sinus infection and, for women, a year’s worth of contraception. Not only that but because of high deductibles (to keep the cost down by discouraging consumption) you are paying $5,000 to the insurance company AND paying cash for your sinus infection visit and medicine. Then there are the drug companies and insurance companies that are colluding to raise the prices of formerly cheap antibiotics to get even more of your household income.

About 1% of the people in this country account for about a quarter (27%) of the health care spending. In 2014, this  was about $100,000 per sick person. Those in the top 5% of sick people were responsible for  almost $50,000 in health care costs. These numbers are unchanged since Obama was elected. So what has changed? Before, the costs of these people were hidden. They would get the care for “free” at a safety net hospital who would get money in other ways to pay for it. Or a sick person would use an insurance card then the payment would be denied as a pre-existing condition and the hospital would eat the cost. More likely, the sick person would get on disability, suffer for 2 years, and become Medicare eligible so we the taxpayer would pay. The care still cost money but was hidden in taxes. Insurance companies kept costs low, in other words, by shifting them to the federal government. Now folks under 65 who are sick can pick up an Obamacare policy and get exceptional care. Also on Obamacare stories are ones like this:

Thank you President Obama thanks to your healthcare plan I was able to continue to see specialists, this resulted in a diagnosis of a rare intestinal infection and even more concerning, two stage three colon cancer tumors, one on each side on each side of the colon. This required almost total colon removal from a top notch physician that was able to do my surgery without having to have a bag.

Only problem is, this type of care costs A LOT more than $5,000. .

So, if you bought an Obamacare policy and feel ripped off, let me tell you what your $5000 paid for. It wasn’t eye glasses and dental work for poor people that jacked up your bill. You spent your $5000 on people under 65 with heart disease and lung disease. You purchased them a lot of expensive tests, some time in the hospital, and some expensive drugs. You paid for the person with breast cancer’s $300,000 tab whose $5000 premiums were paid by the cancer treatment facility.  You paid for the person helicoptered in after rolling their car on Interstate 65 while trying to avoid a deer.  You paid for some very expensive medication for people with mental illness to keep them out of a mental hospital.

Did you pay too much? Yes. Other countries can do the same thing better for half as much or less. Perhaps the new adminstration will look at this as an opportunity to further retool our expensive, not very effective care delivery system and reign in some of the profiteering. Or maybe we’ll just continue to blame the poor…


“And the illusion posted to the feds is that there is a range of options available. And it seems to me that BCBS is basically using the Obamacare turmoil as a cloak for forcing everyone into higher cost plans (and blaming it on the federal law). And, well you know all that. But still.” e-mail from Bill

The system I work for charges about $120 for an office visit to those who are uninsured (increasingly the poor in Alabama). I am an “in-network” provider for Blue Cross of Alabama as well as other insurance companies. This means that I have agreed to accept payment of less than $120 from patients (typically $60 for a routine visit)  in exchange for them referring people to me. The payment generally requires the patient to cough up about $25 up front and me submit a bill (costing my practice about $10) to collect the other $35. The difference between $60 and $120 I never see and is referred to in the office as an “adjustment.” Pre-ObamaCare, I could be fairly certain that if I submitted the bill to Blue Cross I would get the $35. In addition, as an in-network physician if I ordered x-rays or blood work it was paid for no matter where the patient went to get it. If I had a lab in my office I would get paid but, since I don’t, we have a LabCorp draw station in our building. The patient walks 50 feet and stick an arm out and I get the lab results in my electronic health record.

In the post-ObamaCare days, things are a little trickier.ObamaCare required  insurance companies tell tell us a little more about what we are paying for. Remember the list of essential services? When you pay your premium there are 10 things you are supposed to get. No fine print, no bull. One of the 10 things is Laboratory Services. My friend Bill, who is self-employed and purchased an individual Bronze Plan policy (low monthly, high deductible), had an illness. His policy was through Blue Cross of Alabama. He went to an in-network physician who took 50% of what the cash payment would have been (and paid $10 to get some of it from Blue Cross). In good faith he was sent down the hall to get labs (a covered service). He just got his lab bill for $200 which is the full freight, cash price. No adjustment, no Blue Cross portion. My friend Bill, we now know, is virtually uninsured for Labs (and a bunch of other stuff as well).

Here are the fun activities you get to learn about if you have a Blue Cross Bronze plan.  Your money no longer pays for someone to negotiate rates for your labs, x-rays, or surgeries. Better sharpen your negotiating skills.  For you Bronze plans holders, they’ve already negotiated an exclusive contract with Quest who will gladly schedule that stat CBC in Foley, 25 miles away, on Wednesday (true story). Want something a little more convenient, pay full freight. You need a little minor surgery or even major surgery?  My friend Bill will get to employ one of two strategies. The first is to do what he can to get the costs as low as possible. The second will be, rather than worry about the $5 aspirin,  to forfeit his $6000 deductible up front and ask for the single room and steak dinner, secure in the knowledge that they can’t hurt him more.

Turns out that Blue Cross Silver is the plan to get in Alabama, by design. For the extra $81 a  month you pay to Blue Cross, here is what you DON’T have to do. If you need an X-ray, CT, MRI or any other imaging, you DON”T have to negotiate the price yourself. You will pay only $300 a test, no matter how expensive the test is. If you need a lab, you DON’T need to drive over 25 miles to have it done. and then ask them to only process your blood in a single lab in the state. If your in-system doctor orders it, Blue Cross will negotiate for you to get the best price possible from LabCorp or whomever.  You need a little minor surgery or even major surgery? You Silver slackers DON’T need to negotiate the anesthesia fee, surgeon’s fee, or operating room costs.

This likely isn’t tomorrow’s problem. Even with the limited price pressures in the Silver plans (by far the most common), the prices in most states are less this year than they were last year. What this illuminates more than anything else is the crazy and perverse incentives that are currently incorporated in our health care system. We in health care set our prices crazy high and let Blue Cross or some other insurer reduce them arbitrarily. The bill for surgery includes $5 aspirin and $3000 MRIs, prices that no one is expected to pay. Look for the pricing structure to change dramatically in the next 5 years with many things getting bundled together and much greater transparency. Meanwhile, Bill, I understand Humana is looking to compete head to head with Blue Cross in Alabama. You may, however, want to find out which lab they use first before changing.

So last week I talked about how physicians make money not just off of seeing patients but also off of the “mark-up” for medications given in the office. I was asked by the editorial writer at what I really thought and here is what I said:

1) This is only one payer although these are the most expensive patients for the most part. In Alabama, physicians make most of their money form BC/BS so this is only a part of the picture

2) The number is not the take home pay. Think of it as an inventory that they sold. Having said that, physicians take home a lot of money. Orthopedists took home over $400,000 on average in 2012. Even he lowest paid took home $175,000. To do that, though, they shave a little off of everything on that list.

3) There’s a lot on that list that physicians sell that doesn’t make the patients healthier. Next time you as a patient are offered a steroid shot for your cold, question whether or not it is necessary or might it contribute to the chance you will get diabetes. Doctors are doing a lot of stuff to people because people expect it and because insurance pays for it. Under the new insurance plans a lot more little stuff that doesn’t work like steroids for colds will be paid for out of the patient’s pocket. Having a doctor you trust might allow you to ask “is this really necessary?” In fact, you might even be able to ask it via e-mail.

THEN I was asked to put it into layman’s terms and (with A LOT of help from others) we came up with “The tomato version of Medicare spending.” I  will suggest that you go here to read it if you want a neat explanation or ever went to the store hungry for a tomato sandwich and ended up with heirloom tomatoes, foccacia, Maytag blue cheese, and a bill for $200 and wondered “why did I do that?”

barney-tobey-and-remember-kid-you-ve-got-blue-cross-new-yorker-cartoonFrom an anti-trust lawsuit as recounted in How are Blue Cross and Blue Shield Connected?

In the late 1930s, the Blue Cross plans, developed in conjunction with the American Hospital Association, were designed to provide cover the cost of hospital care, while the Blue Shield plans, developed in conjunction with the American Medical Association, were designed to cover all health care. At first, Blue Cross and Blue Shield were strong competitors. But over time, to address competition between each other and other commercial insurers, the Blues agreed to centralize the ownership of their trademarks and trade names. In 1982, Blue Cross Association and the Blue Shield Association merged and the board of directors of the combined associations adopted a strategy not to compete with each other. By 1984 health plan members of the association consolidated at the local level and by 1985 all Blue Cross plans and Blue Shield plans within a state should consolidate so there was only one plan per state.

Conversation at a Christmas Party:

Friend: I have insurance for the first time in years. Looking forward to getting some things fixed

Friend’s partner: Not too much. You know about those high deductibles.

Friend: Let me tell you about this foot. A couple of years back I had a Blue Cross policy and called to see if I could have surgery for this chronic bone spur that’s causing me pain. The nice person on the phone says “Sure, let me just get some information and we’ll get back to you.” After she updates my information I get a letter canceling my policy. I’ve been uninsured since. Now I have my card, and I’m getting my foot fixed. ran a very nice set of stories on Blue Cross of Alabama (and the US) today. In case you are unfamiliar with Blue Cross of Alabama, it provides health insurance for 86% of all non-governmentally provided health care coverage in our state, collects $4 billion in revenue, has $800,000,000 in cash in hand, and has over 7 executives in the $1,000,000 annual salary club. What else do they do with their “savings?”

Mackin said reserves are maintained to protect insured Alabamians from “the burdens of unpaid medical bills.” Reserves are regulated by the Alabama Department of Insurance, she pointed out.

I have previously written quite a bit about Blue Cross of Alabama which I will not repeat. Living in Alabama, you simply get used to Blue Cross being the 800 lb. gorilla. You get used to them having a pre-existing condition clause that precludes adequate care for chronic illnesses and occasionally resulting in bankruptcy as a consequence of a catastrophic illness. You get used to them cancelling policies on a whim. You get used to them dictating that you accept hospital rates that are below Medicare and daring you to challenge them (What’s the worst they can do? Oh, yeah, they can deny you access to 86% of insured patients). In exchange, if you are 27 years old and healthy, you get to pay the least amount for health insurance in the United States. The level of oversight in Alabama is, one might say, minimal. The insurance regulators last reviewed the books in 2009.

The Affordable Care Act is being blamed by Alabamians for increasing the cost of commercial insurance for Alabamians. Those like my friend who had insurance canceled when they tried to use it are much less vocal than those who blame “Obummer” for, well, everything they perceive as bad. The Republicans are still looking for the replace part of “Repeal and Replace” to capture this hatred of all things Obama. They have re-latched onto “sell insurance across state lines to increase competition”  as an alternative. points out that today the Blue Cross confederation already provides insurance for ONE IN THREE Americans in multiple states who are accountable to multiple regulators. Wonder if the Alabama regulators are ready for the national stage?

In a poll of health care executives about the Affordable Care Act, 93% felt that their system would provide measurably better care as a consequence of the implementation of the law. They said it would do this through:

Reducing the number of hospitalizations (54 percent), reducing the number of readmissions (49 percent), and reducing the number of emergency room visits (39 percent). Other likely sources included reducing costs for medical devices (36 percent) and drugs (27 percent), along with improving back office efficiency (23 percent)

They were not asked how they felt about Blue Cross of Alabama taking over the nation’s health care.

Blue Cross of Louisiana is following Dr Berwick’s advice to act locally. For years in Louisiana care was delivered by specialists in the usual disjointed, uncoordinated fashion driven by dominant hospitals and medical schools. On December 2 a summit was held at the Pennington Research Center in Baton Rouge to initiate a sea change in the way care is delivered. They announced the rapid deployment of a primary care based patient centered medical home delivery model. In their press release, they cite the following data as contributing to this change:

According to the review, in South Carolina, patients in the patient-centered medical home started by Blue Cross and Blue Shield had medical and pharmacy costs that were 6.5% lower than the control group. Patients in a similar Blue Cross program in North Dakota saw hospital admissions drop by 6% and emergency room visits fall by 24%. During that same period, in the control group, hospital admissions were up by 45% and emergency room visits rose by 3%.

They go on to say

“The healthcare industry is facing unprecedented change. Blue Cross and Blue Shield of Louisiana has answered the call for new and innovative delivery models by embracing the concept of the patient-centered medical home,” said Mike Reitz, Blue Cross President and CEO.

“Accountable, collaborative, coordinated care delivered through the patient-centered medical home will transform healthcare delivery,” said Dr Kenneth Phenow, Blue Cross Chief Medical Officer. “As an industry, we have evolved as far as we can using costly, fragmented, fee-for-service payment. As we transform, pay-for-value models like those embodied by the PCMH approach will help us achieve better health and better care at a better cost.”

Mike Reitz reiterates his support for the concept as well as the importance of primary care on a video captured by Bayou Buzz found here.

This was e-mailed to me by Paul Grundy under the headline “PCMH as seen explained in the deep red states by an enlightened plan.” Anyone from Alabama listening?

I was at a meeting yesterday with several folks from IBM who were talking about health care. They gave a very good presentation about where health care was going in light of the Affordable Care Act and other policy changes that have occurred. One of the health care executives (from another system here in Mobile) challenged the speaker with what has been the Alabama response:

“Why should we respond to this? When managed care came in the 1990s we were told that capitation would sweep Mobile. It is 2011 and what is our capitation rate? 0%.

“If we just wait it out, this will pass as well. What’s more, the law is likely to be overturned or repealed anyway.”

“Our money’s on Blue Cross”

The response from the speaker was comforting ot those of us who are unhappy with the status quo:

  • The expansion of coverage to adults is already happening. Young adults up to age 26 are now offered coverage on their parents insurance and the vast majority have taken it (thus eliminating 30% of the uninsured). Coming in 2014:

The ACA adds a new category of Medicaid eligibles:  adults under 65 with modified adjusted gross household income (MAGI) at or below 133 percent of poverty.  (Actually, since 5 percent of income is disregarded under the statute, the eligibility level is effectively 138 percent of poverty).  State Medicaid programs will receive 100 percent federal funding for newly eligible enrollees in this category for 2014, 2015, and 2016, gradually phasing down to 90 percent for 2020 and thereafter.  (States that already cover enrollees in this group will gradually receive increased federal funding beginning in 2014 that will reach the same level by 2019).  States may also expand eligibility for adults beyond this limit with their regular federal Medicaid match.

The feds make the rules for Medicaid. As Texas found out, opting out of Medicaid isn’t an option.

  • The insurance market is changed forever. Instead of companies taking a health care hit every year from the insurance companies, the combination of community rating and clearly defined benefits will allow companies to offer a health care benefit that is a defined contribution and takes the risk off of the company. This is already happening in Kansas City

…the Blue exchange is built on a defined contribution model in which employers will give employees a set contribution toward their health insurance and the employees will be able to choose among the available Blue plans. Participating employers will have the option to limit the number of plans available for their employees’ choice or allow them to choose among all 10 options, he said. “This is the consumer-directed health plan model in terms of the consumers having more choices to decide how to spend their health care dollars,” Rowe said. “As a defined contribution model rather than a defined benefit model, it’s like what has happened with pension plans.”

Turns out that Blue Cross is going to have competition

  • Technology is changing everything. This is why IBM is at the table. Data will allow consumers and purchasers to make better informed choices. They have even put together a video showing how data will facilitate these changes whether or not the ACA remains law.

As I was reminded last night, the main provision of Clinton’s health reform package, children need coverage, remained as a legacy even after “Hillarycare” was a distant memory. I think we know what is going to happen. I suspect Blue Cross of Alabama does as well.

Per this news story, a man was suffering from the end stages of alcoholism and ended up in Providence Hospital. He would not have been let in to have his alcoholism treated except that he had his brothers insurance card. His care would have cost $182,030.70 had he not had an insurance card but been allowed to pay cash. Blue Cross paid the hospital $50,898.97 at the completion of his treatment, which Providence accepted as payment in full. He remains sober. The patient is charged with theft of the $50,000 but not the $180,000. Neither Blue Cross nor Providence Hospital is charged with anything.

In my previous post I quote extensively from an article written about Atul Gaeande about primary care physicians (primarily family physicians) who are engaged in trying to reduce healthcare costs for patients who use an extremely large amount of health care. Dr Gawande quotes one of the family physicians, Jefferey Brenner,  as saying that he believes his patients are the same as anyone else. These unfortunate patients have found themselves as a consequence of chance, circumstance, and poor life choices in a situation where they require increasingly to access the health care system to obtain needed services. Dr Brenner sees his job like that of a mother. Someone who cares and is willing to say the same thing over again until the right thing happens.

I thought about this article again as I read an editorial written by Dr Mike McBrearty in the Scope Magazine (the publication of the Alabama Academy of Family Physicians). Unfortunately the editorial is not available online but can be obtained by contacting the Academy here. Dr McBrearty expresses a frustration common for Family Physicians and mothers, one of under-appreciation. Both groups find themselves performing the impossible, molding the behaviors of people who do not want to be molded.While mothers expect payment in non-monetary units (customarily kisses and hugs) physicians tend to expect more tangible rewards, While I have written some on physician reimbursement here some additional information might help illustrate the problem a little more clearly.

The rules for how physicians can submit bills are very convoluted. When Medicare was first established, physicians were able to submit a bill for services to all insurance companies and were paid based on a fee schedule. Typically, all of the physicians in a given community charged about the same thing and fess were set (believe it or not) by doctors who were new to town calling and asking the office staff of the others in town for their charges for certain types of visits. As health care costs rose, Medicare became the benchmark for payment. Private insurers tended to follow Medicare rules and benchmarked their payments for certain procedures on Medicare rates (percent Medicare). In the 1990s there was concern about rising costs in Medicare (sound familiar) and a new type of system was established. The office visit was defined more clearly. It included a history, a physical exam, some type of decision making, and an after visit care component.  This was contrasted with an activity such as a gall bladder removal which included some pre-operative history, the physical exam, the act of removing the gall bladder and closing the body, the care in the hospital after the gall bladder was removed, and the care at home for a period of time after the operation. Both of these activities were considered to be bundled into a global fee, with the schedule set by the insurance company. Physicians could not bill for each of the components that were included in these types of care separately and a language was devised to tell the insurance company what happened called CPT (Common Procedural Terminology) codes. The physician’s office told the insurance company what it expected in the way of payment  by submitting a diagnosis (using ICD-9 terminology) and a types of care provided (using the CPT code). The documentation had to be available to back up what the office said had happened. The fee for hospital care worked well because there was a hospital history, physical, and operative note to support the billing request. The fee for office care office  worked well when it reflected care for acute conditions (an ear infection, for example), the medication choice was simple (penicillin) and the after care was one phone call (I’m not better) with a fairly predictable outcome (then you need to come in). Doctors were expected to make money in the office based on volume (seeing lots of patients for little things).

Where did things go wrong? The amount of work that went into taking out a gall bladder got easier for the physician because hospitals hired people to help with some of the tasks (lab techs, nurses with special training) and the tools made care easier (laproscopic cameras). What used to be a three day event now takes 3 hours. In the office, the tasks became more complex (older patients with more problems, drugs not available on certain insurances, the need to arrange home health care, the need to write justifications for medical equipment) but no one stepped in to help out the doctors in the office by making care easier. In fact, the “enhancements” actually lead to more work for physicians in the office (electronic health records allow better access to information but reduce physician efficiency, drug formularies allow patients access to cheaper drugs but cost the physician time).What used to happen in the hospital over 3 days now happens in the office with the patient not present so the doctor can’t bill for it.  The CPT and ICD-9  language that physicians use to tell insurance companies what they have done does not include the detail needed to describe what really happens.For example,  I get no credit for working to get a patient to stop smoking. In fact, because they are going to be ill less frequently, I will get paid less.

We primary care physicians need to ask for payment to reflect our actual work. The “fee-for-service” model will not allow us to successfully accomplish this. Going back to the mother analogy if the mother only collects kisses when the knee scrape happens, the incentive is not to teach good bike riding habits but instead to teach poor habits and hope for a lot of banged up knees. Fortunately mothers tend to work towards long term outcomes. Some think Accountable Care Organizations will enable us to extract ourselves from this mess and work towards wellness with our patients. I await the new payment rules eagerly.

The Affordable Care Act is under assault in the House of Representatives and the administration is fighting back. The Department of Health and Human Services has issued a report that documents the effects of the repeal of the bill, found here. The investigators found that

Rescinding the new health insurance protections would, now and starting in 2014:

  • Reduce the health care and health insurance options of the 50 to 129 million Americans with pre-existing conditions;
  • Take away, for the 32 to 82 million people with both a pre-existing condition and job-based insurance, the ban on lifetime limits on benefits, restrictions on annual limits on benefits, new protections in the small group market from discrimination based on health status, and the security of knowing you can change jobs without losing your health coverage and care;
  • Lock older Americans into their current coverage if they have it, since up to 86 percent of people ages 55 to 64 have some type of pre-existing condition;
  • Limit insurance options for the parents of the up to 2 million uninsured children with pre-existing conditions, who today can no longer be blocked from purchasing individual market insurance due to their pre-existing condition.

Having cared for people who were denied insurance for preexisting conditions, I can attest to the tenacity of insurance companies in seeking out folks attempting to receive care for illnesses. The statement in our insurance is “known or unknown, manifest or unmanifest” meaning these are not people trying to scam the system, in my experience thaes are people who have a cancer growing inside of them that comes out up to 9 months after taking the job. Prior to the passage of the ACA and until 2014, it kinda sucks to be them.

In a separate article posted on Forbes, Rick Ungar writes on the Republican alternative. I had feared it was to let sick people suffer the consequences of their poor life choices, but it is apparent that the public likes not having the pre-existing condition clause. The Republicans claim to have developed an alternative. He writes

Their answer is to create government supported high-risk insurance pools, operated by the states and funded with federal financial assistance for those with pre-existing medical conditions.

To examine this properly (and you should as the proposal is not without merit), you’ll have to get past the irony that the party of small government wishes to expand government involvement in health care in order to solve the problem of too much government in health care. I know…it’s confusing. However, if you can put this bit of weirdness aside, read on.

He goes on to say that these pools exist today and are poorly funded and underutilized. This is because they have a rather long (12 month) waiting period and are often closed to enrollment for months to years at a time. Oh, yeah, and it’ll cost 10 billion dollars in new taxes to begin to set them up and it’ll perpetuate the current fee-for-service mess. Aside from that, a really good idea.

From a  statement I found in the comments

Careful examination of the facts show that those whom are truly unable to obtain healthcare coverage are not nearly the many millions quoted by the sycophant media. Many are either illegally in our country, young and not covered by choice, or temporarily/by choice not covered for a short amount of time. Medicaid covers the truly needy (as well as those taking advantage inappropriately of Medicaid due to the abysmal administration of Medicaid).

I know based on data that these are not true statements but are they are certainly “deeply held beliefs” in some circles.

There seems to be an attitude  that people who happen to be sick (and many are poor) are that way because of their own culpability or are trying to scam the system to avail themselves of free health care. It is important to people with this belief that undeserving sick folks are made to pay for their healthcare. If we want to prevent every “undeserving” person from obtaining any subsidized health care then I suppose fighting against providing care to people who have the misfortune of getting a job with insurance before their cancer came to the surface makes sense in some warped way. This is how our Senator sees it

[There is a] “big difference between those that have pre-existing conditions and those that are actually negatively affected by them.”

I invite him to follow me while I see some patients one day and see if he can tell who is deserving and who is not.

The Archives of Internal Medicine published an article questioning the conventional wisdom regarding physician selection. In this article they tried to correlate a number of variable with a number of indicators of “quality care” (more on this, later). The authors did find that female sex, board certification (indicating completion of a residency and ability to pass an exam on set intervals), and graduation from a domestic medical school correlated with “significantly” better performance.  Medical malpractice history, interestingly, did not indicate poor medical practices.

When looking more closely at this data, it shows some of the weaknesses of using statistics on numbers to describe behavior. The authors looked at 10,000 physicians and over a million patient encounters. They apparently analysed  all of this information with a statistical package and then looked to see if any of the better performance was seemingly due to something other than chance. They found that all physicians did 62% of the activities that were expected. Female physicians for example were 1.6 percentage points higher than male physicians in regards to performance as a group (and the other differences were equally small). Because of sheer numbers this was seen to be “statistically significant” but given that based on this a random male doctor would be correct 61% of the time compared to the females 63% I think I would find a different way to pick a doctor.

This story was picked up in the lay press by the LA Times. In fairness to the writer, she did point out the weaknesses of the study, pointed out how limited information was for doctor selection, and pointed the reader to an AHRQ website with some pretty good advice:

Look for a doctor who:

      [x] Is rated to give quality care.

      [x] Has the training and background that meet your needs.

      [x] Takes steps to prevent illness-for example, talks to you about quitting smoking.

      [x] Has privileges at the hospital of your choice.

      [x] Is part of your health plan, unless you can you afford to pay extra.

      [x] Encourages you to ask questions.

      [x] Listens to you.

      [x] Explains things clearly.

      [x] Treats you with respect.

The site goes on to explain quality care and offers a checklist to use when interviewing a physician to see if they meet your criteria.

This came up because Blue Cross/Blue Shield of Alabama has decided they are going to try to reward us primary care physicians for delivering “quality care” by increasing the visit fee by 5%. To find out whether I would qualify I decided to look on their Find-A-Doctor website to see where I stand. I was somewhat hesitant because I am an educator in a teaching practice. As such, all of the patients seen  by learners while I am a teaching attending are counted against me in addition to those patients I am personally caring for. I would like to believe our learners are delivering excellent care but belief often is trumped by evidence.

Going beyond the user friendliness of the site (too many poorly categorized physicians with incorrect practice addresses) I am pleased to say that we are delivering good (and sometimes great) care. When measured on screening for certain types of cancer as well as diabetes care we were at or above the national and Alabama average. On the other hand, we do not perform as well as we could.

This measure is done on patients who have come to our office for care. They are not asked if they want for us to provide these services nor are we paid for providing such services. Although my staff, my residents, my colleagues, and myself are certainly motivated to deliver quality care, wouldn’t it be easier if we could dedicate staff to assure quality happened? Wouldn’t it be nice if we could enroll patients to incorporate their wishes and beliefs regarding their healthcare rather than assigning patients to me based on (perhaps) a single visit and assuming they want me to take responsibility for the care plan? Wouldn’t it be better if we were paid well for delivering care for acute illness and equally well for handling chronic illness and preventive services that don’t require a visit. Oh well, at least I’m liked (search for Perkins)  by all 7 of the people who bothered to filled out the survey.